Understanding migraine and psychiatric comorbidity

Anxiety, depression, and headache-related disability in a large pediatric clinic-based sample

OBJECTIVE

To explore the relationships among anxiety, depression, and headache-related disability in a pediatric clinic-based retrospective cross-sectional study.

BACKGROUND

Anxiety and depression are commonly considered comorbidities of headache disorders and are frequently seen in children and adolescents. These conditions can contribute to disability and may have a cumulative impact. In this study, we tested whether self-reported anxiety and/or depression in youth were associated with headache-related disability.

METHODS

This was a retrospective cross-sectional study of children ages 6-17 years old who completed a headache intake questionnaire at the time of a new outpatient neurology visit. Those who reported on behavioral health symptoms, involvement of a behavioral health provider (i.e., yes/no), and the PedMIDAS (a validated metric of headache-related disability) were included. The relationship between anxiety and/or depression and headache-related disability was examined.

RESULTS

Of the 12,660 questionnaires queried, 9118 met criteria for inclusion. Respondents were 64.0% female and had a median age of 13.5 years (interquartile range [IQR] 10.3, 15.7). Compared to patients without self-reported anxiety/depression, patients with anxiety and depression reported higher headache-related disability (M = 17.0, [IQR 6.0, 41.0]) even after accounting for covariates (estimated difference = 6.0, 95% confidence interval [CI: 4.4-7.5]). For participants with anxiety and/or depression, having a behavioral health provider was associated with greater headache-related disability (estimated difference = 7.0; 95% CI 4.6-9.3).

CONCLUSIONS

Patients with self-reported anxiety and/or depression reported higher headache-related disability. Having a behavioral health provider was associated with greater headache-related disability, indicating the complexity and high level of need for this population. Further research is needed to understand the directionality of these results; however, patients with headache as well as depression and or anxiety are a vulnerable group who may benefit from an integrated care model.

Development of the Migraine-Related Stigma (MiRS) Questionnaire: Results of the OVERCOME (US) Study

BACKGROUND

Stigma is emerging as an important social contributor to migraine-related disability and other outcomes. Currently, there are no published validated measures of migraine-specific measures of stigma.

OBJECTIVES

This secondary post hoc analysis of a cross-sectional cohort study aimed to develop a questionnaire to evaluate migraine-related stigma.

METHODS

Based on focus group discussions among persons with migraine and literature review, a panel of migraine experts iteratively developed 12 candidate items for the migraine-related stigma (MiRS) questionnaire, which aims to measure if and how people living with migraine perceive they are viewed in a stigmatizing manner by others. The United States ObserVational survey of the Epidemiology tReatment and Care Of MigrainE (OVERCOME) study identified people with active migraine within a demographically representative United States (US) adult sample and administered the novel MiRS questionnaire in addition to questionnaires assessing sociodemographics, monthly headache days, and migraine disability score (Migraine Disability Assessment) among other data. Exploratory factor analysis was then utilized to evaluate the structure of the MiRS items and determine the Cronbach's alpha described internal consistency of the factors.

RESULTS

This exploratory factor analysis was a secondary post hoc analysis of a cross-sectional cohort study derived from the OVERCOME population-based web survey, which was conducted in a United States sample of 61,932 adults with migraine. The mean (standard deviation) age was 41.7 (14.8) years, 74.5% (n = 46,122) were female, and 70.3% (n = 43,564) identified as White. Two factors were identified: MiRS-external perception of Secondary Gain (eigenvalue = 21.5, percentage of total variance = 88.9%) and MiRS-external perception of Minimizing Burden of migraine (eigenvalue = 2.7, percentage of total variance = 11.1%). The two factors were correlated (r = 0.66) and a non-orthogonal varimax rotation showed that eight items loaded onto the MiRS-Secondary Gain factor, and four items loaded onto the MiRS-Minimizing Burden factor.

CONCLUSION

This population-based study of >60,000 people with migraine allowed the development and validation of the first migraine-specific measure of perceived external stigma for people with migraine. This study demonstrated that MiRS consists of two internally consistent subscales: Secondary Gain and Minimizing Burden. This may be a useful tool for quantifying perceived migraine-related stigma to understand determinants of migraine-related stigma and test interventions to reduce perceived migraine-related stigma.

What is the Status Quo of Patient-Centred Physiotherapy Management of People with Headache within a Biopsychosocial Model? - A Narrative Review

PURPOSE OF REVIEW

Patient-centred care (PCC) is deemed essential in the rehabilitation of musculoskeletal pain. Integrating such care within a biopsychosocial framework, enables to address all facets of the individual pain experience, and to manage the individual instead of the condition. This narrative review describes the status quo of PCC physiotherapy management of people with headache within a biopsychosocial model. PubMed, EMBASE, Web of Science, Scopus were searched (update 07.05.2024). The search-query comprised terminology relating to "headache", "patient-centred", "biopsychosocial", "physiotherapy". Additional eligibility criteria were reviews, trials, cohort, case report, case-control studies in English, Dutch, French.

RECENT FINDINGS

Gaps are exposed in patient-centred physiotherapy management of migraine, tension-type headache, and cervicogenic headache. While a biopsychosocial approach is advised to manage migraine and tension-type headache, its use in clinical practice is not reflected by the literature. A biopsychosocial approach is not advised in cervicogenic headache. Psychosocial-lifestyle interventions are mainly delivered by health-care providers other than physiotherapists. Additionally, psychologically-informed practice is barely introduced in physiotherapy headache management. Though, managing the social context within a biopsychosocial framework is advised, the implementation by physiotherapists is unclear. Comparable conclusions apply to PCC. PCC is recommended for the physiotherapy management of primary and secondary headache. Such recommendation remains however theoretical, not reaching clinical implementation. Yet, a shift from the traditional disease-centred model of care towards PCC is ongoing and should be continued in physiotherapy management. With this implementation, clinical and economical studies are needed to evaluate its effectiveness.

Effects of probiotic and vitamin D co-supplementation on clinical symptoms, mental health, and inflammation in adult patients with migraine headache: a randomized, triple-blinded, placebo-controlled trial

BACKGROUND

Migraine headache is a major public health problem. Routine medications for migraine treatment are not useful in treating all patients and may have some side effects. The present study aimed to investigate the effect of vitamin D and probiotic co-supplementation on clinical characteristics of migraine, daily functioning, mental health outcomes, and serum levels of high-sensitivity C-reactive protein (hs-CRP).

METHODS

In this randomized, triple-blinded, placebo-controlled trial, patients aged 18 to 55 years diagnosed with migraine based on the International Classification of Headache Disorders-3 (ICHD-3) were randomized to either vitamin D (50,000 IU every 2 weeks) plus probiotic (4.5 × 1011 CFU per day) or placebo for 12 weeks. The Headache Impact Test (HIT-6) and Depression, Anxiety, and Stress Scale (DASS) questionnaires were administered to patients at baseline and after 12 weeks. In addition, the frequency, duration, and severity of migraine headaches per month were assessed using a self-administered 30-day headache diary at baseline and the end of the intervention. Anthropometric indices, blood pressure, and serum levels of 25-hydroxy vitamin D and hs-CRP were also examined at first and the end of the study.

RESULTS

Seventy-two migraine patients with a mean age of 37.46 ± 8.32 years were included in this trial. Probiotic and vitamin D co-supplementation compared to placebo resulted in a significant increase in serum levels of vitamin D (+ 12.86 ± 1.64 vs. + 1.12 ± 0.80 ng/mL, P < 0.001). The between-group analysis in the adjusted model showed a significantly greater reduction in migraine headache frequency (- 3.17 ± 0.84 vs. - 1.25 ± 0.34; P = 0.031) and severity (- 1.55 ± 0.35 vs. + 0.67 ± 0.29; P = 0.017) in the probiotic and vitamin D group than the placebo group. No significant difference was found between the two arms of the intervention regarding the change in headache duration, hs-CRP, scores of DASS, and HIT-6 questionnaires (P > 0.05).

CONCLUSIONS

This trial showed that probiotic and vitamin D co-supplementation for 12 weeks has beneficial effects on migraine headache characteristics. Further research is needed to confirm this finding.

The role of hypertension in the relationship between leisure screen time, physical activity and migraine: a 2-sample Mendelian randomization study

BACKGROUND

The relationship between lifestyle and migraine is complex, as it remains uncertain which specific lifestyle factors play the most prominent role in the development of migraine, or which modifiable metabolic traits serve as mediators in establishing causality.

METHODS

Independent genetic variants strongly associated with 20 lifestyle factors were selected as instrumental variables from corresponding genome-wide association studies (GWASs). Summary-level data for migraine were obtained from the FinnGen consortium (18,477 cases and 287,837 controls) as a discovery set and the GWAS meta-analysis data (26,052 cases and 487,214 controls) as a replication set. Estimates derived from the two datasets were combined using fixed-effects meta-analysis. Two-step univariable MR (UVMR) and multivariable Mendelian randomization (MVMR) analyses were conducted to evaluate 19 potential mediators of association and determine the proportions of these mediators.

RESULTS

The combined effect of inverse variance weighted revealed that a one standard deviation (SD) increase in genetically predicted Leisure screen time (LST) was associated with a 27.7% increase (95% CI: 1.14-1.44) in migraine risk, while Moderate or/and vigorous physical activity (MVPA) was associated with a 26.9% decrease (95% CI: 0.61-0.87) in migraine risk. The results of the mediation analysis indicated that out of the 19 modifiable metabolic risk factors examined, hypertension explains 24.81% of the relationship between LST and the risk of experiencing migraine. Furthermore, hypertension and diastolic blood pressure (DBP) partially weaken the association between MVPA and migraines, mediating 4.86% and 4.66% respectively.

CONCLUSION

Our research findings indicated that both LST and MVPA in lifestyle have independent causal effects on migraine. Additionally, we have identified that hypertension and DBP play a mediating role in the causal pathway between these two factors and migraine.

Risk of depression after Parkinson's disease, stroke, multiple sclerosis, and migraine in an Iranian population and assess psychometric characteristics of three prevalent depression questionnaires

Objective

We aim to evaluate the prevalence of depression in disorders including multiple sclerosis (MS), Parkinson's disease (PD), migraine, and stroke. Also, we detect risk factors for depression occurrence within each disorder. Moreover, we compare the risk factors in these four common neurologic disorders. In advance, we assess the three surveys in order to better comprehend their distinctions.

Background

Depression is a globally prevalent Psychologic disorder and common co-morbidity in neurological diseases. However, it is mostly underdiagnosed in chronic patients and causes numerous adverse effects.

Methods

We used the database of neurology specialty clinics in a hospital in Tehran, the largest city of Iran. Five hundred nineteen patients, including 105 PD patients, 101 patients with stroke, 213 cases with MS, and 100 Migraine patients, were assessed. They were asked about their chief characteristics and disease-specific variables that may cause depression. Moreover, depression criteria were measured with three internationally used scales to study their variances.

Results

Overall, the prevalence of depression in PD, stroke, MS, and migraine, according to the BDI-II scale, were 43.8%, 38.6%, 45.1%, 37.6%, and according to HDRS scale, were 56.2%, 51.5%, 39.4%, and 43.6% respectively. Finally, according to DSM-XC the depression prevalence were 64.8%, 34.7%, 36.2%, and 67.3% respectively. Possible risk factors of depression were lower educational level, disease severity, socioeconomic level, marital or employment status, female gender, higher age, and consumption of some specific drugs.

Conclusion

Depression is a widespread disorder in chronic neurologic conditions. Our data suggests the odds of depression in neurologic disorders depend on the characteristics of the patient and the features of the disease.

Migraine-Related Stigma and Its Relationship to Disability, Interictal Burden, and Quality of Life: Results of the OVERCOME (US) Study

BACKGROUND AND OBJECTIVES

This population-based analysis characterizes the relative frequency of migraine-related stigma and its cross-sectional relationship to migraine outcomes. We hypothesized that migraine-related stigma would be inversely associated with favorable migraine outcomes across headache day categories.

METHODS

OVERCOME (US) is a web-based observational study that annually recruited a demographically representative US sample and then identified people with active migraine using a validated migraine diagnostic questionnaire. It also assessed how frequently respondents experienced migraine-related stigma using a novel 12-item questionnaire (Migraine-Related Stigma, MiRS) that contained 2 factors; feeling that others viewed migraine as being used for Secondary Gain (8 items, α = 0.92) and feeling that others were Minimizing disease Burden (4 items, α = 0.86). We defined 5 groups: (1) MiRS-Both (Secondary Gain and Minimizing Burden often/very often; (2) MiRS-SG (Secondary Gain often/very often); (3) MiRS-MB (Minimizing Burden often/very often); (4) MiRS-Rarely/Sometimes; (5) MiRS-Never. Using MiRS group as the independent variable, we modeled its cross-sectional relationship to disability (Migraine Disability Assessment, MIDAS), interictal burden (Migraine Interictal Burden Scale-4), and migraine-specific quality of life (Migraine Specific Quality of Life v2.1 Role Function-Restrictive) while controlling for sociodemographics, clinical features, and monthly headache day categories.

RESULTS

Among this population-based sample with active migraine (n = 59,001), mean age was 41.3 years and respondents predominantly identified as female (74.9%) and as White (70.1%). Among respondents, 41.1% reported experiencing, on average, ≥4 monthly headache days and 31.7% experienced migraine-related stigma often/very often; the proportion experiencing migraine-related stigma often/very often increased from 25.5% among those with <4 monthly headache days to 47.5% among those with ≥15 monthly headache days. The risk for increased disability (MIDAS score) was significant for each MiRS group compared with the MiRS-Never group; the risk more than doubled for the MiRS-Both group (rate ratio 2.68, 95% CI 2.56-2.80). For disability, interictal burden, and migraine-specific quality of life, increased migraine-related stigma was associated with increased disease burden across all monthly headache day categories.

DISCUSSION

OVERCOME (US) found that 31.7% of people with migraine experienced migraine-related stigma often/very often and was associated with more disability, greater interictal burden, and reduced quality of life.

Peripheral Endocannabinoid Components and Lipid Plasma Levels in Patients with Resistant Migraine and Co-Morbid Personality and Psychological Disorders: A Cross-Sectional Study

Resistant migraine characterizes those patients who have failed at least three classes of migraine prophylaxis. These difficult-to-treat patients are likely to be characterized by a high prevalence of psychological disturbances. A dysfunction of the endocannabinoid system (ECS), including alteration in the levels of endocannabinoid congeners, may underlie several psychiatric disorders and the pathogenesis of migraines. Here we explored whether the peripheral gene expression of major components of the ECS and the plasma levels of endocannabinoids and related lipids are associated with psychological disorders in resistant migraine. Fifty-one patients (age = 46.0 ± 11.7) with resistant migraine received a comprehensive psychological evaluation according to the DSM-5 criteria. Among the patients, 61% had personality disorders (PD) and 61% had mood disorders (MD). Several associations were found between these psychological disorders and peripheral ECS alterations. Lower plasma levels of palmitoiletanolamide (PEA) were found in the PD group compared with the non-PD group. The MD group was characterized by lower mRNA levels of diacylglycerol lipase α (DAGLα) and CB2 (cannabinoid-2) receptor. The results suggest the existence of peripheral dysfunction in some components of the ECS and an alteration in plasma levels of PEA in patients with resistant migraine and mood or personality disorders.

Debate: differences and similarities between tension-type headache and migraine

Tension-type headache (TTH) and migraine are two common primary headaches distinguished by clinical characteristics according to the 3^rd edition of the International Classification of Headache Disorders. Migraine is identified by specific features such as being more prevalent in females, being aggravated by physical activity, certain genetic factors, having photophobia, phonophobia, nausea, vomiting, or aura, and responding to specific drugs. Nonetheless, TTH and migraine share some common characteristics, such as onset occurring in the 20 s, and being triggered by psychological factors like stress, moderate pain severity, and mild nausea in chronic TTH. Both conditions involve the trigeminovascular system in their pathophysiology. However, distinguishing between TTH and migraine in clinical practice, research, and epidemiological studies can be challenging, as there is a lack of specific diagnostic tests and biomarkers. Moreover, both conditions may coexist, further complicating the diagnostic process. This review aims to explore the similarities and differences in the pathophysiology, epidemiology, burden and disability, comorbidities, and responses to pharmacological and non-pharmacological treatments of TTH and migraine. The review also discusses future research directions to address the diagnostic challenges and improve the understanding and management of these conditions.

The Relationship of Tobacco Use and Migraine: A Narrative Review

PURPOSE OF REVIEW

Tobacco use is associated with significant health consequences especially for people with medical conditions. Although lifestyle strategies (e.g., sleep, diet) are commonly recommended as part of migraine treatment, tobacco-related strategies (e.g., smoking cessation) are rarely included. This review is aimed at elucidating what is known about tobacco use and migraine and at identifying gaps in the research.

RECENT FINDINGS

The prevalence of smoking is higher among people with migraine, and people with migraine believe that smoking makes migraine attacks worse. There is also evidence that smoking may exacerbate migraine-related consequences (e.g., stroke). Very few studies have examined other aspects of smoking and migraine or tobacco products other than cigarettes. There are significant gaps in our knowledge of smoking and migraine. More research is needed to understand the relationship of tobacco use to migraine and potential benefits of adding smoking cessation efforts into migraine care.

Effect of a Craniosacral Therapy Protocol in People with Migraine: A Randomized Controlled Trial

Background: Migraine is a common neurological disorder, and it is the second leading cause of disability worldwide. Manual techniques based on physical therapy have been proposed to improve migraine aspects; however, further research is needed on their effectiveness. The aim of this study was to evaluate the effectiveness of a craniosacral therapy protocol on different features in migraine patients. Methods: Fifty individuals with migraine were randomly divided into two groups (n = 25 per group): (i) craniosacral therapy group (CTG), following a craniosacral therapy protocol, and (ii) sham control group (SCG), with a sham treatment. The analyzed variables were pain, migraine severity and frequency of episodes, functional, emotional, and overall disability, medication intake, and self-reported perceived changes, at baseline, after a 4 week intervention, and at 8 week follow-up. Results: After the intervention, the CTG significantly reduced pain (p = 0.01), frequency of episodes (p = 0.001), functional (p = 0.001) and overall disability (p = 0.02), and medication intake (p = 0.01), as well as led to a significantly higher self-reported perception of change (p = 0.01), when compared to SCG. In addition, the results were maintained at follow-up evaluation in all variables. Conclusions: A protocol based on craniosacral therapy is effective in improving pain, frequency of episodes, functional and overall disability, and medication intake in migraineurs. This protocol may be considered as a therapeutic approach in migraine patients.

The involvement of orexin 1 and cannabinoid 1 receptors within the ventrolateral periaqueductal gray matter in the modulation of migraine-induced anxiety and social behavior deficits of rats

Orexin 1 receptors (Orx1R) and cannabinoid 1 receptors (CB1R) are implicated in migraine pathophysiology. This study evaluated the potential involvement of Orx1R and CB1R within the ventrolateral periaqueductal gray matter (vlPAG) in the modulation of anxiety-like behavior and social interaction of migraineurs rats. A rat model of migraine induced by recurrent administration of nitroglycerin (NTG) (5 mg/kg/i.p.). The groups of rats (n = 6) were then subjected to intra-vlPAG microinjection of orexin-A (25, 50 pM), and Orx1R antagonist SB334867 (20, 40 nM) or AM 251 (2, 4 μg) as a CB1R antagonist. Behavioral responses were evaluated in elevated plus maze (EPM), open field (OF) and three-chambered social test apparatus. NTG produced a marked anxiety like behaviors, in both EPM and OF tasks. It did also decrease social performance. NTG-related anxiety and social conflicts were attenuated by orexin-A (25, 50 pM). However, NTG effects were exacerbated by SB334867 (40 nM) and AM251 (2, 4 μg). The orexin-A-mediated suppression of NTG-induced anxiety and social conflicts were prevented by either SB334867 (20 nM) or AM251 (2 μg). The findings suggest roles for Orx1R and CB1R signaling within vlPAG in the modulation of migraine-induced anxiety-like behavior and social dysfunction in rats.

Psychological predictors of negative treatment outcome with Erenumab in chronic migraine: data from an open label long-term prospective study

Background

Monoclonal antibodies (mABs) targeting the calcitonin gene-related peptide (CGRP) pathway represent the first disease-specific preventive migraine therapy. Growing evidence suggests that they are effective in the preventive treatment of difficult-to-treat patients. In this study, we evaluated the psychological predictors of the outcome of treatment with the anti-CGRP monoclonal antibody erenumab in patients with chronic migraine (CM).

Methods

Seventy-five patients with CM who had already failed at least 3 preventive therapies received erenumab every 28 days for a period of 12 months. Before the first administration, patients received a full psychological evaluation using The Structured Clinical Interview for DSM-5 Clinician Version (SCID-5-CV) to assess personality disturbances (primary outcome), mood and anxiety disorders, and as well specific questionnaires to evaluate alexithymia traits, childhood traumas, and current stressors (secondary outcomes).

Results

After 12 months of treatment, 53 patients reported a reduction of at least 50% in headache days/per month (Responders), whereas 22 did not (Non Responders). When compared to Responders, Non Responders were characterized by a higher prevalence of personality disorders belonging to Cluster C (avoidant, dependent, and obsessive-compulsive) (77% vs 37%, p = .001). Non Responders were also characterized by a higher prevalence of anxiety disorders (90% vs 60%, p = 0.007), showed more alexithymic traits (51.7 ± 13.7 vs 42.9 ± 14.3, p = 0.017), and reported a higher number of 'at least serious' current stressors (3.2 ± 4.0 vs 0.8 ± 1.4, p < .0001) than Responders. At the multivariate analysis, higher prevalence of Cluster C personality disorders (OR 3.697; p = 0.05) and higher number of ‘at least serious’ life events (OR 1.382; p = 0.017) arose as prognostic factors of erenumab failure.

Conclusions

Erenumab confirmed its effectiveness in a population of difficult-to-treat migraine. The presence of “anxious-fearful” personality together with current stressors and anxiety represent negative predictors of treatment outcome.

Trial registration

The study protocol was registered at clinicaltrials.gov (NCT04361721).

The efficacy of alpha-lipoic acid in improving oxidative, inflammatory, and mood status in women with episodic migraine in a randomised, double-blind, placebo-controlled clinical trial

AIM

Migraine is a common neurovascular disorder, which is associated with severe to moderate disabling headaches. Oxidative stress and inflammation might play a role in migraine pathogenesis and the mood disorders. Considering the antioxidant and anti-inflammatory properties of alpha-lipoic acid (ALA), this study was designed to investigate its effect on oxidative, inflammatory, and mood conditions in women with episodic migraine.

METHODS

In total, 92 women with episodic migraine participated in the study. The patients were randomly divided into two groups, receiving a 300-mg capsule of ALA or placebo twice daily for 3 months. To assess the oxidative and inflammatory status, the serum levels of total antioxidant capacity (TAC), total oxidant status (TOS), glutathione (GSH), malondialdehyde (MDA), oxidative stress index (OSI), and C-reactive protein (CRP) were determined at the beginning and at the end of the intervention. A depression, anxiety, stress scale (DASS-21-items) questionnaire was used to evaluate mood status.

RESULTS

Finally, 79 patients reached the final analysis stage. At the end of the intervention, a significant decrease in the serum levels of MDA (means difference [MD]: -0.83, 95% confidence intervals (CI): -1.04, -0.62 nmol/mL vs MD: -0.32, CI: -0.48, -0.15 nmol/mL; P < .001) and CRP (MD: -0.78, CI: -1.17, -0.39 mg/L vs MD: -0.63, CI: -1.80, 0.52 mg/L; P < .001) was observed in the ALA as compared with the placebo group, but changes in serum GSH (P = .086), TAC (P = .068), TOS (P = .225), and OSI (P = .404) were not statistically significant. In addition, depression, anxiety, and stress (with P < .001, in all cases) had significantly decreased in the intervention as compared with the control group.

CONCLUSION

The results of this study suggest that ALA supplementation for 3 months has beneficial effects on improving the oxidative, inflammatory, and mood conditions of patients suffering from episodic migraine.

Effectiveness of a manual therapy protocol based on articulatory techniques in migraine patients. A randomized controlled trial

BACKGROUND

Physiotherapy is used as a non-pharmacological treatment for migraine. However, controversy exists over whether articulatory manual techniques are effective in some aspects related to migraine.

OBJECTIVES

To assess the effectiveness of a manual therapy protocol based on articulatory techniques in pain intensity, frequency of episodes, migraine disability, quality of life, medication intake and self-reported perceived change after treatment in migraine patients.

DESIGN

Randomized controlled trial.

METHODS

Fifty individuals with migraine were randomized into the experimental group, which received manual therapy based on articulatory techniques (n = 25), or the placebo group (n = 25). The intervention lasted 4 weeks and included 4 sessions. Patients were assessed before (T1), after (T2) and at a one-month follow-up following the intervention (T3). The instruments used were the Migraine Disability Assessment (MIDAS) questionnaire, the Short Form-36 Health Survey (SF-36), the medication intake and The Patients' Global Impression of Change scale.

RESULTS

In comparison with placebo group, manual therapy patients reported significant effects on pain intensity at T2 (p < 0.001; d = 1.15) and at T3 (p < 0.001; d = 1.13), migraine disability at T3 (p < 0.05; d = 0.69), physical quality of life at T2 (p < 0.05; d = 0.72), overall quality of life at T2 (p < 0.05; d = 0.60), decrease in medication intake at T2 (p < 0.001; d = 1.11) and at T3 (p < 0.05; d = 0.77) and self-reported perceived change after treatment at T2 and T3 (p < 0.001). No serious adverse events were reported.

CONCLUSIONS

The application of a manual therapy protocol based on articulatory techniques reduced pain intensity, migraine disability, and medication intake, while improving quality of life in patients with migraine.

Using Monozygotic Twins to Dissect Common Genes in Posttraumatic Stress Disorder and Migraine

Epigenetic mechanisms have been associated with genes involved in Posttraumatic stress disorder (PTSD). PTSD often co-occurs with other health conditions such as depression, cardiovascular disorder and respiratory illnesses. PTSD and migraine have previously been reported to be symptomatically positively correlated with each other, but little is known about the genes involved. The aim of this study was to understand the comorbidity between PTSD and migraine using a monozygotic twin disease discordant study design in six pairs of monozygotic twins discordant for PTSD and 15 pairs of monozygotic twins discordant for migraine. DNA from peripheral blood was run on Illumina EPIC arrays and analyzed. Multiple testing correction was performed using the Bonferroni method and 10% false discovery rate (FDR). We validated 11 candidate genes previously associated with PTSD including DOCK2, DICER1, and ADCYAP1. In the epigenome-wide scan, seven novel CpGs were significantly associated with PTSD within/near IL37, WNT3, ADNP2, HTT, SLFN11, and NQO2, with all CpGs except the IL37 CpG hypermethylated in PTSD. These results were significantly enriched for genes whose DNA methylation was previously associated with migraine (p-value = 0.036). At 10% FDR, 132 CpGs in 99 genes associated with PTSD were also associated with migraine in the migraine twin samples. Genes associated with PTSD were overrepresented in vascular smooth muscle, axon guidance and oxytocin signaling pathways, while genes associated with both PTSD and migraine were enriched for AMPK signaling and longevity regulating pathways. In conclusion, these results suggest that common genes and pathways are likely involved in PTSD and migraine, explaining at least in part the co-morbidity between the two disorders.

Migraine and stress-an exploratory cross-country study of external stress factors

OBJECTIVE

The data collected by the Global Burden of Disease 2016 project indicate that migraine ranks second in high-income countries with very competitive and flexible labour markets, and first in low- and middle-income countries suffering from civic unrest and conflict. This raises the question whether external stress factors may be correlated with migraine years lived with disability per 100,000 inhabitants (YLD). The objective of this exploratory study is to test the hypothesis that external stress factors are correlated with the prevalence and severity of migraine at the country level. The analysis uses two country groups: developed and developing countries. For the first group, the proxy variables for stress are labour productivity and unemployment rate. For the second group, the proxy variables measure conflict-related deaths and share of migrant/refugee population.

RESULTS

The results show a positive relationship between the stress variables on the one hand and migraine YLD on the other hand for both country groups. Almost all results are statistically significant at p < 0.01. These exploratory findings suggest that societal stress factors may be potential candidates for modifiable factors for the prevalence and/or severity of migraine at the country level.

Severe migraine and its control: A proposal for definitions and consequences for care

Currently many patients with severe migraine do not receive appropriate treatment and are never referred to specialist headache centres. On the other hand, specialist headache centres are frequently attended by patients whose migraines could be managed adequately in the community. One reason for this may be the absence of standardised definitions of migraine severity and control and of a treatment algorithm for orientating difficult-to-treat patients to specialist headache centres. Based on a review of the relevant literature and consensus meetings, proposals have been made for these items. We propose that migraine should be considered severe if headache frequency is at least eight migraine days per month or, if headaches are less frequent, the HIT-6 score is ≥60 or ≥50% of headaches require complete interruption of activity. The proposed definition of migraine control is defined on the basis of appropriate response to acute headache therapy and to preventative therapy. A treatment algorithm is proposed to assess migraine control regularly and to adapt therapy accordingly. These proposals may contribute to developing and testing strategies for management of severe disease with appropriate and effective preventive treatment strategies. With the anticipated introduction of new possibilities for migraine prevention in the near future, the time is ripe for a holistic approach to migraine management.

Cortical Thickness in Migraine: A Coordinate-Based Meta-Analysis

Cortical thickness (CTh) via surface-based morphometry analysis is a popular method to characterize brain morphometry. Many studies have been performed to investigate CTh abnormalities in migraine. However, the results from these studies were not consistent and even conflicting. These divergent results hinder us to obtain a clear picture of brain morphometry regarding CTh alterations in migraine. Coordinate-based meta-analysis (CBMA) is a promising technique to quantitatively pool individual neuroimaging studies to identify consistent brain areas involved. Electronic databases (PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure, WanFang, and SinoMed) and other sources (bioRxiv and reference lists of relevant articles and reviews) were systematically searched for studies that compared regional CTh differences between patients with migraine and healthy controls (HCs) up to May 15, 2020. A CBMA was performed using the Seed-based d Mapping with Permutation of Subject Images approach. In total, we identified 16 studies with 17 datasets reported that were eligible for the CBMA. The 17 datasets included 872 patients with migraine (average sample size 51.3, mean age 39.6 years, 721 females) and 949 HCs (average sample size 59.3, mean age 44.2 years, 680 females). The CBMA detected no statistically significant consistency of CTh alterations in patients with migraine relative to HCs. Sensitivity analysis and subgroup analysis verified this result to be robust. Metaregression analyses revealed that this CBMA result was not confounded by age, gender, aura, attack frequency per month, and illness duration. Our CBMA adds to the evidence of the replication crisis in neuroimaging research that is increasingly recognized. Many potential confounders, such as underpowered sample size, heterogeneous patient selection criteria, and differences in imaging collection and methodology, may contribute to the inconsistencies of CTh alterations in migraine, which merit attention before planning future research on this topic.

Efficacy of Galcanezumab for Migraine Prevention in Patients With a Medical History of Anxiety and/or Depression: A Post Hoc Analysis of the Phase 3, Randomized, Double-Blind, Placebo-Controlled REGAIN, and Pooled EVOLVE-1 and EVOLVE-2 Studies

OBJECTIVE

This post hoc analysis evaluated the efficacy of galcanezumab for the prevention of migraine in patients with and without comorbid anxiety and/or depression.

BACKGROUND

Patients with migraine have a higher risk of anxiety and/or depression. Given the high prevalence of psychiatric symptoms and their potential negative prognostic impact, determining the efficacy of migraine treatments in patients with these comorbidities is important.

METHODS

The results of 2 phase 3 episodic migraine studies of patients with 4-14 migraine headache days (MHD) per month were pooled. A third chronic migraine study, which was evaluated separately, enrolled patients with ≥15 headache days per month, of which ≥8 had migraine-like features. Patients in all 3 studies were randomized 2:1:1 to placebo, galcanezumab 120 mg, or galcanezumab 240 mg. The efficacy of galcanezumab on migraine was measured in subgroups of patients with anxiety and/or depression (current or past) and patients without. A repeated measures model was used to compare treatment groups within each subgroup and to test for consistency of treatment effect across the anxiety/depression subgroups (subgroup-by-treatment interaction) during the double-blind treatment phases.

RESULTS

Among 1773 intent-to-treat patients with episodic migraine, both doses of galcanezumab demonstrated statistically significant improvements relative to placebo in overall number of MHD for the subgroups of patients with anxiety and/or depression (mean change difference from placebo [95% CI]: -2.07 [-2.81, -1.33] for galcanezumab 120 mg [P < .001], -1.91 [-2.78, -1.04] for 240 mg [P < .001]) and without anxiety and/or depression (mean change difference from placebo [95% CI]: -1.92 [-2.36, -1.47] for 120 mg [P < .001], -1.77 [-2.20, -1.33] for 240 mg [P < .001]), as was observed for the secondary outcomes of MHD with acute medication use and functional impairment. Among 1113 intent-to-treat patients with chronic migraine, those with anxiety and/or depression had significant reductions in overall MHD frequency with the 240-mg dose (mean change difference from placebo [95% CI]: -1.92 [-3.52, -0.33]; P = .018), whereas significant reductions were observed at both the 120-mg (mean change difference from placebo [95% CI]: -2.29 [-3.26, -1.31]; P < .001) and 240-mg (-1.85 [-2.83, -0.87]; P < .001) doses in patients without anxiety and/or depressions. Significant reductions (P < .01) in MHD with acute medication use were observed at both doses within both anxiety/depression subgroups and for overall functional impairment for patients without anxiety and/or depression, though neither dose significantly reduced overall functional impairment beyond placebo in the subgroup with anxiety and/or depression. In the episodic and chronic migraine studies, the subgroup-by-treatment interaction was not statistically significant for MHD, MHD with acute medication use, or functional impairment (chronic study only), suggesting a lack of evidence of differential effect between subgroups. Furthermore, differences between subgroups in the mean change differences from placebo, as well as overlapping 95% confidence intervals for the subgroups, indicated lack of a clinical or statistical difference between subgroups for these outcome variables. There was a significantly higher percentage of patients with episodic migraine attaining ≥50%, ≥75%, and 100% reductions, and a higher percentage of patients with chronic migraine attaining ≥50% and ≥75% reductions from baseline with galcanezumab compared with placebo, regardless of medical history of anxiety and/or depression.

CONCLUSIONS

A medical history of anxiety and/or depression does not seem to interfere with response to galcanezumab among patients with episodic migraine, and both doses of galcanezumab appear efficacious for these individuals regardless of this psychiatric history. Among patients with chronic migraine and comorbid anxiety and/or depression, the 240-mg dose, but not the 120-mg dose, significantly decreased overall MHD, but neither dose resulted in significantly greater functional improvement. Patients with migraine and comorbid anxiety and/or depression often require additional interventions, and this may be more important in chronic migraine.

The Effect of Psychiatric Comorbidities on Headache-Related Disability in Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

OBJECTIVE

To examine the influences of depression and anxiety on headache-related disability in people with episodic migraine or chronic migraine.

BACKGROUND

Depression and anxiety are common comorbidities in people with migraine, especially among those with chronic migraine.

METHODS

This cross-sectional analysis of data from the longitudinal, internet-based Chronic Migraine Epidemiology and Outcomes Study assessed sociodemographic and headache features, and headache-related disability (Migraine Disability Assessment Scale). Four groups were defined based on scores from validated screeners for depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder Scale): depression alone, anxiety alone, both, or neither.

RESULTS

Respondents (N = 16,788) were predominantly women (74.4% [12,494/16,788]) and white (84.0% [14,044/16,788]); mean age was 41 years. Depression was more likely in persons with chronic migraine vs episodic migraine (56.6% [836/1476] vs 30.0% [4589/15,312]; P < .001), as were anxiety (48.4% [715/1476] vs 28.1% 4307/15,312]; P < .001) and coexisting depression and anxiety (42.0% [620/1476] vs 20.8% [3192/15,312]; P < .001). After controlling for headache frequency and other covariates, depression alone, and anxiety alone were associated with 56.0% (rate ratio [RR], 1.56; 95% confidence interval [CI], 1.46-1.66) and 39.0% (RR, 1.39; 95% CI, 1.30-1.50) increased risks of moderate/severe migraine-related disability (both P < .001), respectively; the combination had an even greater effect on risk of moderate/severe disability (79.0% increase; RR, 1.79; 95% CI, 1.71-1.87; P < .001).

CONCLUSIONS

Depression alone and anxiety alone are associated with greater headache-related disability after controlling for sociodemographic and headache features. Coexisting depression and anxiety are more strongly associated with disability than either comorbidity in isolation. Interventions targeting depression and anxiety as well as migraine itself may improve headache-related disability in people with migraine.

Using Cognitive Behavioral Therapy Techniques to Treat Migraine

Migraine is a common and disabling neurologic disorder that often occurs alongside anxiety and mood disorders. Information is provided on the biological basis of the disorder, the interactive effects of co-morbidity, and common psychological distortions manifested by individuals with migraine. Psychological treatments based on cognitive behavioral techniques have demonstrated efficacy to treat migraine. Migraine treatment can be incorporated in private practice and integrated care settings.

Factors Related to Migraine Patients' Decisions to Initiate Behavioral Migraine Treatment Following a Headache Specialist's Recommendation: A Prospective Observational Study

Objective

To evaluate the frequency with which migraine patients initiated behavioral migraine treatment following a headache specialist recommendation and the predictors for initiating behavioral migraine treatment.

Methods

We conducted a prospective cohort study of consecutive patients diagnosed with migraine to examine whether the patients initiated behavioral migraine treatment following a provider recommendation. The primary outcome was scheduling the initial visit for behavioral migraine treatment. Patients who initiated behavioral migraine treatment were compared with those who did not (demographics, migraine characteristics, and locus of control) with analysis of variance and chi-square tests.

Results

Of the 234 eligible patients, 69 (29.5%) were referred for behavioral treatment. Fifty-three (76.8%) patients referred for behavioral treatment were reached by phone. The mean duration from time of referral to follow-up was 76  (median 76, SD = 45) days. Thirty (56.6%) patients initiated behavioral migraine treatment. There was no difference in initiation of behavioral migraine treatment with regard to sex, age, age of diagnosis, years suffered with headaches, health care utilization visits, Migraine Disability Assessment Screen, and locus of control (P > 0.05). Patients who had previously seen a psychologist for migraine were more likely to initiate behavioral migraine treatment than patients who had not. Time constraints were the most common barrier cited for not initiating behavioral migraine treatment.

Conclusions

Less than one-third of eligible patients were referred for behavioral treatment, and only about half initiated behavioral migraine treatment. Future research should further assess patients' decisions regarding behavioral treatment initiation and methods for behavioral treatment delivery to overcome barriers to initiating behavioral migraine treatment.

Is allergic rhinitis related to migraine disability in adults?

OBJECTIVE

Migraine is a chronic condition with complex pathophysiology. Although immunologic disturbances have been linked to migraine, only few attempts have been made to assess the possibility of allergic rhinitis as a worsening factor of migraine in adults. This survey aimed to compare migraine disability between adult migraineurs with and without current allergic rhinitis.

METHODS

This cross-sectional study comprised 118 adult migraineurs who were consecutively assisted at an outpatient clinic. After ordinary neurological evaluation, participants were evaluated for headache disability using the Migraine Disability Assessment (MIDAS). The presence of current allergic rhinitis, allergic rhinoconjunctivitis and seasonal allergic rhinitis was scored for each participant according to the International Study of Asthma and Allergies in questionnaire.

RESULTS

There was no significant difference between the MIDAS scores of those with current allergic rhinitis, allergic rhinoconjunctivitis, or seasonal allergic rhinitis and nonatopic migraineurs. The disability caused by allergic symptoms also did not influence the MIDAS scores of patients with allergic rhinitis. The frequency of headache days during the last three months was higher in the subset of patients without allergic rhinitis (median and interquartile range 12 [8-19.2] vs. 8 [4-14]; p = 0.03).

CONCLUSIONS

Our results suggest that current allergic rhinitis, allergic rhinoconjunctivitis, and seasonal allergic rhinitis are not related to headache disability in adults with episodic migraine.

Anxiety Sensitivity as a Risk Indicator for Anxiety, Depression, and Headache Severity in Women With Migraine

OBJECTIVE

The primary aim of this exploratory study was to assess the relationship between anxiety sensitivity and emotional disorders, migraine characteristics, and migraine-related fear and avoidance behaviors in women with probable migraine.

BACKGROUND

Anxiety and depressive disorders are the most frequent comorbid psychiatric conditions in migraine, particularly in women; however, the underlying reasons for these comorbidities are uncertain. Anxiety sensitivity, the tendency to catastrophically appraise anxiety and bodily sensations in terms of their physical, social, or cognitive consequences, is a psychological factor that may contribute to the comorbidity of anxiety and depressive disorders and migraine. It was hypothesized that anxiety sensitivity would be associated with greater migraine severity and psychiatric symptoms.

METHOD

Participants were women (n = 100) who screened positive for migraine on the validated IDMigraine Screener participated in an anonymous single-session online survey-based study on migraine. The Anxiety Sensitivity Index-3 total and subscales scores were used to assess anxiety sensitivity. Anxiety and depression symptoms were assessed with the brief Patient Health Questionnaire.

RESULTS

On average, anxiety sensitivity was clinically elevated (mean ± SD: 24.0 ± 15.2). Anxiety sensitivity cognitive and social concerns were most strongly correlated with severity of anxiety (r's = .38-.46) and depressive symptoms (r = .35-.39, P's < .001), and all anxiety sensitivity facets were related to fear of head pain (r's = .35-.38, P's < .001). Anxiety sensitivity cognitive concern facet was uniquely related to headache patterns, including longer migraine attack duration (r = .22, P = .029) and pain intensity (r = .24, P = .029), pain-related avoidance, including avoiding movement and more frequent misuse of prescribed or non-prescribed pain medication (r's = .20-.21, P's < .01).

CONCLUSIONS

These novel findings indicate that anxiety sensitivity, specifically fearful appraisal of bodily sensations, are linked to both psychiatric symptoms and migraine severity in women. In this cross-sectional study, causal sequence cannot be determined. If anxiety sensitivity leads to more severe pain and psychiatric distress, targeting anxiety sensitivity could lead to better headache outcomes.

Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications

BACKGROUND

Migraine is a highly prevalent and disabling neurological disorder which is commonly linked with a broad range of psychiatric comorbidities, especially among subjects with migraine with aura or chronic migraine. Defining the exact nature of the association between migraine and psychiatric disorders and bringing out the pathophysiological mechanisms underlying the comorbidity with psychiatric conditions are relevant issues in the clinical practice.

METHODS

A systematic review of the most relevant studies about migraine and psychiatric comorbidity was performed using "PubMed", "Scopus", and "ScienceDirect" electronic databases from 1 January 1998 to 15 July 2018. Overall, 178 studies met our inclusion criteria and were included in the current review.

RESULTS

According to the most relevant findings of our overview, the associations with psychiatric comorbidities are complex, with a bidirectional association of major depression and panic disorder with migraine. Importantly, optimizing the pharmacological and non-pharmacological treatment of either migraine or its psychiatric comorbidities might help clinicians to attenuate the burden of both these conditions.

CONCLUSIONS

The available data highlight the need for a comprehensive evaluation of psychiatric disorders in migraine in order to promote an integrated model of care and carefully address the burden and psychosocial impairment related to psychiatric comorbidities in migraine.

Anxiety, Incentives, and Adherence to Self-Monitoring on a Mobile Health Platform: A Naturalistic Longitudinal Cohort Study in People With Headache

OBJECTIVE

To evaluate factors associated naturalistically with adherence to a mobile headache diary.

BACKGROUND

Self-monitoring (keeping a headache diary) is commonly used in headache to enhance diagnostic accuracy and evaluate the effectiveness of headache therapies. Mobile applications are increasingly used to facilitate keeping a headache diary. Little is known about the factors associated with adherence to mobile headache diaries.

METHODS

In this naturalistic longitudinal cohort study, people with headache (n = 1561) registered to use Curelator Headache® (now called N1-Headache®), an application that includes a mobile headache diary, through their physician (coupon), or directly through the website or app store using either a paid or free version of the application. Participants completed baseline questionnaires and were asked to complete daily recordings of headache symptoms and other factors for at least 90 days. Baseline questionnaires included headache characteristics and migraine disability. Daily recordings included headache symptoms and anxiety ratings. Adherence to keeping the headache diary was conceptualized as completion (kept the headache diary for 90 days), adherence rate (proportion of diary days completed 90 days after registration), and completion delay (the number of days past 90 days after registration required to complete 90 days of headache diary).

RESULTS

The majority of participants reported migraine as the most common headache type (90.0%), and reported an average of 30.8 headache days/90 days (SD = 24.2). One-third of participants completed 90 days of headache diary (32.4%). Endorsing higher daily anxiety scores (8/10 OR = 0.97 [95% CI = 0.96, 0.99]; 10/10 OR = 0.96 [95% CI = 0.91, 0.99]) was associated with lower odds of completion, whereas higher age (OR = 1.04 [95% CI = 1.03, 1.05]), and downloading the app paid vs free (OR = 4.27 [95% CI = 2.62, 7.06]), paid vs coupon (OR = 2.43, 95% CI = 1.41, 4.26]), or through a physician coupon vs free (OR = 1.75 [95% CI = 1.27, 2.42]) were associated with higher odds of completion. The median adherence rate at 90 days was 0.34 (IQR = 0.10-0.88), indicating that half of participants kept 34 or fewer days 90 diary days after registration. Endorsing high daily anxiety scores (5/10 OR = 0.98 [95% CI = 0.97, 1.00]; 8/10 OR = 0.96 [95% CI = 0.94, 0.98]; 10/10 OR = 0.96 [9% CI = 0.92, 0.98]) and higher age (OR = 1.05 [95% CI = 1.04, 1.07]) were associated with lower odds of adhering at 90 days, whereas downloading the app paid vs free (OR = 9.63 [95% CI = 4.61, 25.51]), paid vs coupon (OR = 2.39, 95% CI = 1.27, 5.10]), or through a physician coupon vs free (OR = 4.01 [95% CI = 2.54, 7.26]) were associated with higher odds of adhering at 90 days. Among completers, the median completion delay was 6.0 days (IQR = 2.0-15.0). Among completers, endorsing high daily anxiety scores (9/10 OR = 1/06 [95% CI = 1.01, 1.12]) and younger age (OR = 0.98 [95% CI = 0.97, 1.00]) was associated with completion delay; downloading the app through physician coupon vs free (OR = 0.40 [95% CI = 0.22, 0.71]) or paid vs free (OR = 0.38 [95% CI = 0.20, 0.72]) was associated with lower odds of completing 90 diary days in 90 calendar days.

CONCLUSION

This naturalistic observational study confirmed evidence from clinical observation and research: adherence to mobile headache diaries is a challenge for a significant proportion of people with headache. Endorsing higher levels of daily anxiety, younger age, and downloading the app for free (vs either paying for the self-monitoring app or receiving a physician referral coupon) were associated with poorer adherence to keeping a mobile headache diary.

Chronic migraine, comorbidity, and socioeconomic deprivation: cross-sectional analysis of a large nationally representative primary care database

Background

Chronic migraine is common but there is limited knowledge on associated comorbidities.

Objectives

To examine mental and physical comorbidities in chronic migraine and the influence of socioeconomic status in a large, nationally representative dataset.

Design

Analysis of cross-sectional primary healthcare data from 1,468,404 adults in Scotland. Chronic migraine, 31 other physical conditions, and seven mental health conditions we examined. Prevalence rates were standardized by age groups, sex, and socioeconomic deprivation, and adjusted odds ratio (aOR) and 95% confidence intervals (CI) calculated for those with chronic migraine compared with those without.

Results

Chronic migraine patients had more conditions, with the biggest difference found for five or more conditions (chronic migraine 11.7% vs. controls 4.9%; aOR 3.00; 95% CI 2.78-3.22). Twenty-five of the 31 physical conditions were significantly more prevalent in the chronic migraine group. The biggest difference was for chronic pain (aOR 4.33; 95% CI 4.12-4.55). For mental health conditions, the biggest differences were for anxiety (aOR 2.95; 95% CI 2.76-31.5) and depression (aOR 2.94; 95% CI 2.81-3.08). Increasing deprivation was associated with more severe and complex comorbidity (five or more conditions), and with more combined mental and physical comorbidity in the chronic migraine group.

Conclusions

In a large nationally representative sample in primary care, comorbidity was most common in those with chronic migraine compared with standardized controls, and this was exacerbated by living in areas of higher deprivation.

Kappa opioid receptor antagonists: A possible new class of therapeutics for migraine prevention

Background Stress is the most commonly reported migraine trigger. Dynorphin, an endogenous opioid peptide acting preferentially at kappa opioid receptors (KORs), is a key mediator of stress responses. The aim of this study was to use an injury-free rat model of functional cephalic pain with features of migraine and medication overuse headache (MOH) to test the possible preventive benefit of KOR blockade on stress-induced cephalic pain. Methods Following sumatriptan priming to model MOH, rats were hyper-responsive to environmental stress, demonstrating delayed cephalic and extracephalic allodynia and increased levels of CGRP in the jugular blood, consistent with commonly observed clinical outcomes during migraine. Nor-binaltorphimine (nor-BNI), a long-acting KOR antagonist or CYM51317, a novel short-acting KOR antagonist, were given systemically either during sumatriptan priming or immediately before environmental stress challenge. The effects of KOR blockade in the amygdala on stress-induced allodynia was determined by administration of nor-BNI into the right or left central nucleus of the amygdala (CeA). Results KOR blockade prevented both stress-induced allodynia and increased plasma CGRP. Stress increased dynorphin content and phosphorylated KOR in both the left and right CeA in sumatriptan-primed rats. However, KOR blockade only in the right CeA prevented stress-induced cephalic allodynia as well as extracephalic allodynia, measured in either the right or left hindpaws. U69,593, a KOR agonist, given into the right, but not the left, CeA, produced allodynia selectively in sumatriptan-primed rats. Both stress and U69,593-induced allodynia were prevented by right CeA U0126, a mitogen-activated protein kinase inhibitor, presumably acting downstream of KOR. Conclusions Our data reveal a novel lateralized KOR circuit that mediated stress-induced cutaneous allodynia and increased plasma CGRP in an injury-free model of functional cephalic pain with features of migraine and medication overuse headache. Selective, small molecule, orally available, and reversible KOR antagonists are currently in development and may represent a novel class of preventive therapeutics for migraine.